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Common Skin Disorders Of The Penis
 

Common Skin Disorders Of The Penis

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Review of penile skin disorders

Review of penile skin disorders

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    Common Skin Disorders Of The Penis Common Skin Disorders Of The Penis Presentation Transcript

    • Common skin disorders of the penis Main reference: BJU International 2002 S.A. BUECHNER Department of Dermatology, University of Basel, Switzerland Urology Conference Presented by: Ahmad Kharrouby PGY3
    • Outline
    • Outline
      • A-Viral infections
        • Genital warts
        • Genital herpes
      • B-Bacterial ulcerative lesions
        • Chancre ( Syphilis)
        • Chancroid (H. ducreyi )
      • C-Infestations
        • Scabies
        • Pediculosis pubis
      • D-Cutaneous diseases
        • Psoriasis
        • Lichen planus
        • Penile lichen sclerosus
        • Contact dermatitis
        • Fixed-drug eruptions
      • E-Balanitis and balanoposthitis
        • Plasma cell balanitis
        • Balanitis circinata
      • F-Premalignant and malignant genital tumours
        • Giant condyloma
        • Bowen’s disease
        • Bowenoid papulosis
        • Erythroplasia of Queyrat
        • Penile SCC
    • A-Viral infections 1- Genital warts 2-Genital herpes
    • 1- Genital warts
    • A-Viral infections 1- Genital warts
      • The most common sexually transmitted disease
      • Caused by HPV
      • 1 percent of all sexually active adults have genital warts
      • 10% can be documented to have active HPV by PCR
      • Elevated genital warts, condyloma acuminata, are due to low-risk HPV types (usually 6 and 11)
      • Occur mostly under the prepuce, and on the penile shaft
    • A-Viral infections 1- Genital warts
      • There are three major types of anogenital warts:
        • Condyloma acuminata are pedunculated, cauliflower-like, skin-coloured to reddish verrucous papules
        • Dome-shaped, usually flesh coloured papules
        • Flat warts are flat-topped papules which may vary in colour from pink-red to reddish-brown
    • Multiple papular pigmented condylomata acuminata on the penile shaft
    • Numerous whitish condylomata acuminata on the tip of the penis
    • A-Viral infections 1- Genital warts
      • Current treatments can eradicate only the warts and not the virus, recurrence is very common (>25%)
      • There are 2 basic forms of therapy:
        • Patient applied
        • Health-care worker applied
    • A-Viral infections 1- Genital warts
      • Patient-applied treatment:
        • Podophyllotoxin is applied twice daily for 3 days per week for 6–10 weeks
        • Imiquimod is an immune modulator that results in the local production of interferon, It is applied once daily for three times per week
    • A-Viral infections 1- Genital warts
      • Physician-applied treatments include:
        • Liquid nitrogen cryotherapy
        • Electrocautery
        • Laser therapy
        • Intralesional or systemic immunotherapies
    • 2- Genital herpes
    • A-Viral infections 2- Genital herpes
      • The most common cause of genital ulcers
      • Is an incurable and recurrent viral infection
      • Sexually transmitted
      • Is predominantly caused by HSV type 2
      • HSV-1 is responsible for 5–30% of cases of first-episode
      • After infection, the viral genome remains in a latent state in the nuclei of sensory neurons for the life of the host
      • Genital HSV-1 infections are usually less severe and less prone to recur than those caused by HSV- 2
    • A-Viral infections 2- Genital herpes
      • Appears as macules and papules, followed by vesicles, pustules and ulcers
      • Systemic complaints including fever, myalgias and lethargy may be present, but are rare
      • Patients will often have accompanying tender lymphadenitis
    • Genital herpes; grouped vesicles and erosions are located on the penis shaft and scrotum
    • A-Viral infections 2- Genital herpes
      • Recurrent episodes are less severe and undergo rapid involution within 5– 10 days
      • Recurrence rate reach 90% in HSV 2
      • Diagnosis can be confirmed by virus isolation in cell culture or by PCR
    • A-Viral infections 2- Genital herpes
    • B-Bacterial ulcerative lesions 1-Chancre ( Syphilis) 2-Chancroid (H. ducreyi )
    • 1- Chancre ( Syphilis)
    • B-Bacterial ulcerative lesions 1- Chancre ( Syphilis)
      • Caused by the spirochete Treponema pallidum
      • Occurs during the first stage of syphilis i.e.Primary syphilis
      • Is an ulcerative lesion at the site of spirochete entry
      • Appears about 3-4 weeks after infection
      • The chancre is usually hard and painless
      • The lesions typically clear after about a month without scarring
      • Serologic tests are often negative when the chancre first appears but become reactive in the following 1-4 weeks
    • Syphilitic chancres may appear on or around the genitals
    • B-Bacterial ulcerative lesions 1- Chancre ( Syphilis)
      • Definitive diagnosis involves demonstration of Treponema pallidum by darkfield microscopy in lesions
      • Treatment of primary syphilis is Benzathine penicillin G, 2.4 million units IM as a single dose
    • 2-Chancroid (H. ducreyi )
    • B-Bacterial ulcerative lesions 2-Chancroid (H. ducreyi )
      • Chancroid is an acute ulcerative disease, often associated with inguinal adenopathy (“bubo”)
      • H. ducreyi , a gram-negative facultative bacillus, is the cause
      • Definitive diagnosis of chancroid requires identification H. ducreyi , on specialized culture media that are not widely available
    • B-Bacterial ulcerative lesions 2-Chancroid (H. ducreyi )
      • In practice, a probable diagnosis of chancroid may be based on the following:
        • the patient has a painful genital ulcer
        • there is no evidence of T. pallidum by darkfield examination
        • an HSV test is negative
        • the clinical appearance is typical
    •  
    • B-Bacterial ulcerative lesions 2-Chancroid (H. ducreyi )
      • Treatment of chancroid is Azithromycin, 1 g as a single oral dose
      • or ceftriaxone, 250 mg as a single IM dose
      • or ciprofloxacin, 500 mg orally twice a day for 3 days
    • C-Infestations 1-Scabies 2-Pediculosis pubis
    • 1-Scabies
    • C-Infestations 1- Scabies
      • Caused by human mite Sarcoptes scabiei
      • Causes a severely pruritic, widespread eruption
      • Very itchy papules or nodules with a central crust on the penile shaft or glans and on the scrotum
      • In adults, scabies is a sexually transmitted disease
    • Scabies; multiple erythematous papules
    • C-Infestations 1- Scabies
      • Treatment consists of overnight application of 5% permethrin cream to the whole body from the neck down
      • To be repeated in 1 week
      • All sexual partners should be treated simultaneously
      • All clothing, bedding, and towels should be washed and heat dried
    • 2-Pediculosis pubis
    • C-Infestations 2-Pediculosis pubis
      • Pediculosis pubis may be sexually or nonsexually transmitted
      • Itching may be intense
      • The nits are found on the hair shafts in the pubic area and the eyelids
    •  
    • The nits are found on the hair shafts in the pubic area and the eyelids
    • C-Infestations 2-Pediculosis pubis
      • Treatment consists of application of permethrin 1% crème rinse applied for 10 minutes then washed off
      • To be repeated in 1 week
      • All hairy areas contiguous with the genital area should be treated
      • The sexual partner(s) should be treated also
      • All clothing, bedding, and towels should be washed and heat dried
    • D-Cutaneous diseases 1-Psoriasis 2-Lichen planus 3-Penile lichen sclerosus 4-Contact dermatitis 5-Fixed-drug eruptions
    • 1-Psoriasis
    • D-Cutaneous diseases 1- Psoriasis
      • A solitary plaque may present on the glans penis, leading to confusion with high-grade dysplasia (erythroplasia of Queyrat)
      • Itching may be intense or nonexistent
      • The diagnosis usually can be made by inspection and by noting other areas of involvement such as the scalp, elbows, knees, and nails
    • Psoriasis; red scaly patches on the glans penis
    •  
    • D-Cutaneous diseases 1- Psoriasis
      • Hydrocortisone cream, 1%
      • plus an imidazole cream (clotrimazole, 1%) is usually efficacious
      • Washing the glans after intercourse is critical in controlling penile psoriasis
    • 2- Lichen planus
    • D-Cutaneous diseases 2- Lichen planus
      • Lichen planus may affect the glans penis
      • The genitalia may be the only site of involvement
      • The lesions are polygonal, violet-hued, flat-topped papules, with shiny surfaces
      • Lesions may be asymptomatic, pruritic, or painful if eroded
      • A biopsy may be required
    • Lichen planus; numerous annular violaceous papules on the glans penis
    • D-Cutaneous diseases 2- Lichen planus
      • Topical corticosteroids and topical tacrolimus 0.1% ointment
      • The disease may disappear after months to years
    • 3- Lichen Sclerosis
    • D-Cutaneous diseases 3- Lichen Sclerosis
      • LS almost inevitably involves the anogenital regions, where severe pruritus or painful erosions may develop
      • LS of the glans penis may lead to phimosis and urethral stenosis
    • Lichen sclerosus; a typical white sclerotic ring at the tip of foreskin
    • D-Cutaneous diseases 3- Lichen Sclerosis
      • Topical steroids are the treatment of choice
      • An initial trial should be 6 weeks of treatment
      • Once the patient is in remission, milder steroids or bland emollients may be used for maintenance
    • 4- Contact dermatitis
    • Cutaneous diseases 4- Contact dermatitis
      • True allergic contact dermatitis is pruritic, erythematous, edematous, and weepy
      • Possible causes are hygiene products, condoms, and plants
    • D-Cutaneous diseases 4-Contact dermatitis
      • Twice-daily cool water compresses
      • Followed immediately by the application of a mild topical steroid (1% hydrocortisone ointment)
    • 5- Fixed-drug eruptions
    • D-Cutaneous diseases 5- Fixed-drug eruptions
      • Fixed drug eruption, due usually to laxatives sulfonamides, or NSAIDs, commonly presents on the genitalia
      • Two percent of all genital ulcers are fixed drug eruptions
      • Lesions often begin within a day of drug exposure and present as bright red to violaceous macules that quickly blister and erode
    • Fixed drug eruption caused by ingestion of trimethoprim-sulphamethoxazole, showing the dusky erythematous solitary lesion
    • D-Cutaneous diseases 5- Fixed-drug eruptions
      • The erosion is superficial and broad (usually >1 cm)
      • Fixed drug eruption occurs in the same site with each exposure to the same drug
      • Treatment is to stop the offending medication
    • E-Balanitis and balanoposthitis 1-Plasma cell balanitis 2-Balanitis circinata
    • 1-Plasma cell balanitis
    • E-Balanitis and balanoposthitis 1- Plasma cell balanitis
      • Is a benign chronic balanitis of unknown origin
      • The condition usually manifests in middle-aged or elderly uncircumcised men
      • Plasma cell balanitis is characterized by a solitary red-orange plaque of the glans and prepuce
      • The plaque surface is shiny and smooth, slightly moist
    • Plasma cell balanitis; a well circumscribed, shiny red plaque
    • E-Balanitis and balanoposthitis 1- Plasma cell balanitis
      • The disease tends to be chronic and may persist for months to years
      • It is important to verify the diagnosis by biopsy
      • The histopathology is characteristic showing a band-like infiltrate of plasma cells
    • E-Balanitis and balanoposthitis 1- Plasma cell balanitis
      • The treatment of choice for is circumcision
      • Temporary relief is usually achieved by a topical steroid
    • 2- Balanitis circinata
    • E-Balanitis and balanoposthitis 2- Balanitis circinata
      • Balanitis circinata is a mucocutaneous manifestation of Reiter’s syndrome
      • A multisystem disease, that is clinically characterized by the triad of nongonococcal urethritis, arthritis and conjunctivitis
      • Manifests as a well-demarcated, moist, erythematous plaque with a ragged or scalloped white border on the glans penis
    • Balanitis circinata; well-demarcated, erythematous plaque with a ragged border on the glans penis
    • F-Premalignant and malignant genital tumours 1-Giant condyloma 2-Bowen’s disease 3-Bowenoid papulosis 4-Erythroplasia of Queyrat 5-Penile SCC
    • 1-Giant condyloma
    • F-Premalignant and malignant genital tumours 1- Giant condyloma
      • Giant condylomata acuminata are cauliflower-like lesions arising from the prepuce or glans
      • Most cases are caused by infection with low risk HPV 6 and 11
      • These lesions may be difficult to distinguish from well-differentiated squamous cell carcinoma
      • Most represent a subtype of low-grade SCC
      • Deep biopsies are needed
    • Giant condylomata acuminata are cauliflower-like lesions arising from the prepuce or glans
    • 2-Bowen’s disease
    • F-Premalignant and malignant genital tumours 2-Bowen’s disease
      • Bowen’s disease is a squamous cell carcinoma in situ typically involving the penile shaft
      • The lesion appears as a red plaque with encrustations
      • Surgical excision is the best treatment option for small lesions, preferably by cryosurgery or CO2 laser
    • 3- Bowenoid papulosis
    • F-Premalignant and malignant genital tumours 3- Bowenoid papulosis
      • Similar to Bowen’s but multiple papules instead of plaques
      • Bowenoid papulosis is a high grade intraepithelial lesion
      • Bowenoid papulosis is characterized by flat, skin-coloured, pink or often hyperpigmented papules
      • Is strongly associated with HPV 16
      • Occurs mainly in young sexually active adults, with lesions on the glans and prepuce
    • Bowenoid papulosis; multiple flat pigmented papules
    • F-Premalignant and malignant genital tumours 3- Bowenoid papulosis
      • The most effective treatment is excision of the papules
      • However, cryosurgery with liquid nitrogen and carbon dioxide laser are the most frequently used method
    • 4-Erythroplasia of Queyrat
    • F-Premalignant and malignant genital tumours 4-Erythroplasia of Queyrat
      • Is a velvety, red lesion with ulcerations that usually involve the glans
      • Microscopic examination shows typical, hyperplastic cells in a disordered array with vacuolated cytoplasm and mitotic figures
      • Surgical excision is the treatment of choice, but topical 5-fluorouracil and the CO2 laser may also be used
    • Erythroplasia of Queyrat is a velvety, red lesion with ulcerations
    • 5-Penile SCC
    • F-Premalignant and malignant genital tumours 5-Penile SCC
      • Of all cancers affecting the penis 95% are SCC
      • The disease is rare
      • The age at the onset of penile SCC has a wide range (20– 90 years) with a peak around the fifth decade
      • Risk factors are
        • Phimosis
        • Lack of circumcision
        • Chronic inflammatory conditions
        • Multiple sexual partners
        • HPV infection
    • F-Premalignant and malignant genital tumours 5-Penile SCC
      • The clinical appearance of penile SCC varies from
        • erythematous plaque
        • induration
        • verrucous lesions
        • exophytic lesions
        • irregularly shaped mass
      • As it increases in size, superficial ulceration, necrosis and bleeding may become evident
    • Penile SCC presenting as an erythematous, nodular, erosive lesion on the glans penis
    • Squamous cell carcinoma exophytic erosive lesion with evident keratanization
    • F-Premalignant and malignant genital tumours 5-Penile SCC
      • The treatment of penile SCC depends on tumour staging and includes surgery, radiotherapy, laser surgery and chemotherapy
    • References
      • BJU International (2002), Common skin disorders of the penis, S.A. BUECHNER, Department of Dermatology, University of Basel, Switzerland
      • Smith’s General Urology, Seventeenth Edition, Skin Diseases of the External Genitalia, Timothy G. Berger, MD
    • Thank You